Adherence counseling practices of generalist and specialist physicians caring for people living with HIV/AIDS in North Carolina

A population-based study of self-reported adverse drug events among Lebanese outpatients

There is a limited number of studies assessing the epidemiology of Adverse Drug Events (ADEs) in the outpatient setting, especially those that do not result in healthcare use. The primary objective of this study was to assess the prevalence and determinants of self-reported ADEs among Lebanese outpatients. It was a cross-sectional observational study performed among Lebanese outpatients visiting community pharmacies across Lebanon. A questionnaire was designed to elicit patients’ relevant information. The association between categorical variables were evaluated using Pearson χ² test or Fisher's exact test. Binary logistic regression was performed to identify factors that affect the experience of self-reported ADEs. The study comprised 3148 patients. Around 37% of patients reported experiencing an ADE in the previous year. When ADEs occur, 70.5% of the respondents reported informing their physicians. Increasing number of medications per patient, use of injectable medication, and inquiring about potential drug-drug interactions were associated with higher experience of ADEs (p = 0.049; p = 0.003; and p = 0.009 respectively). Patients who received hospital discharge counseling reported experiencing less ADEs (p = 0.002). Our study showed prevalence of ADEs among Lebanese outpatients especially patients with polypharmacy, and highlighted the need to educate patients about the importance of reporting ADEs to their physicians.

Using Real-Time Adherence Feedback to Enhance Communication About Adherence to Antiretroviral Therapy: Patient and Clinician Perspectives

New technologies for real-time adherence monitoring hold the potential to enhance antiretroviral therapy adherence interventions by providing objective information about daily medication-taking behavior. To realize this potential, we need to understand how to integrate real-time adherence feedback into existing best practices to promote antiretroviral therapy adherence at the point of care. Using in-depth interviews with 30 HIV-infected patients and 29 HIV care clinicians, our primary aims were to understand patients' and clinicians' perceptions of anticipated benefits and preferred uses of objective feedback to enhance conversations about adherence and to identify concerns about the impact of objective monitoring on patient-clinician relationships and communication. Both patients and clinicians suggested that identifying patterns of nonadherence with real-time feedback could (a) facilitate collaborative adherence problem-solving, (b) motivate patient adherence, and (c) reinforce the importance of optimal adherence. Some clinicians worried that delivery of real-time feedback could imply mistrust of patient-reported adherence and suggested careful framing of monitoring results. A few patients and clinicians were concerned that negative reactions to monitoring could discourage retention in care and reduce adherence motivation. These results indicate the potential of real-time feedback to enhance existing evidence-based adherence interventions targeting the key adherence precursors of adherence information, motivation, and behavioral skills. Guidance for the delivery of real-time adherence feedback should focus on both optimizing adherence and mitigating negative perceptions of adherence monitoring.

Delivery of HIV Antiretroviral Therapy Adherence Support Services by HIV Care Providers in the United States, 2013 to 2014

BACKGROUND

Little is known about clinicians' adoption of recommendations of the International Association of Providers of AIDS Care and others for supporting adherence to antiretroviral therapy (ART).

METHODS

We surveyed a probability sample of US HIV care providers to estimate the percentage offering 3 ART adherence support services to most or all patients and assessed the characteristics of providers offering all 3 services (comprehensive support) to most or all patients.

RESULTS

Almost all providers (95.5%) discussed ART adherence at every visit, 60.1% offered advice about tools to increase adherence, 53.5% referred nonadherent patients for supportive services, and 42.8% provided comprehensive support. Nurse practitioners were more likely to offer comprehensive support as were providers who practiced at Ryan White HIV/AIDS Program-funded facilities, provided primary care, or started caring for HIV-infected patients within 10 years.

CONCLUSION

Less than half of HIV care providers offered comprehensive ART adherence support. Certain subgroups may benefit from interventions to increase delivery of adherence support.

Retention and mortality outcomes from a community-supported public-private HIV treatment programme in Myanmar

Introduction

There is a growing interest in the potential contribution the private sector can make towards increasing access to antiretroviral therapy (ART) in low- and middle-income settings. This article describes a public–private partnership that was developed to expand HIV care capacity in Yangon, Myanmar. The partnership was between private sector general practitioners (GPs) and a community-based non-governmental organization (International HIV/AIDS Alliance).

Methods

Retrospective analysis of 2119 patient records dating from March 2009 to April 2015 was conducted. Outcomes assessed were immunological response, loss to follow-up, all-cause mortality, and alive and retained in care. Follow-up time was calculated from the date of registration to the date of death, loss to follow-up, transfer out, or if still alive and known to be in care, until April 2015. Cox proportional hazards model was used to identify predictors of loss to follow-up and mortality. Kaplan–Meier survival analysis was used to estimate survival function of being alive and retained in care.

Results

The median number of patients for each of the 16 GPs was 42 (interquartile range (IQR): 25–227), and the median follow-up period was 13 months. The median patient age was 35 years (IQR: 30–41); 56.6% were men, 62 and 11.8% were in WHO Stage III and Stage IV at registration, respectively; median CD4 count at registration was 177 cells/mm³; and 90.7% were on ART in April 2015. The median CD4 count at registration increased from 122 cells/mm³ in 2009 to 194 cells/mm³ in 2014. Among patients on ART, CD4 counts increased from a median of 187 cells/mm³ at registration to 436 cells/mm³ at 36 months. The median time to initiation of ART among eligible patients was 29 days, with 93.8% of eligible patients being initiated on ART within 90 days. Overall, 3.3% patients were lost to follow-up, 4.2% transferred out to other health facilities, and 8.3% died during the follow-up period. Crude mortality rate was 48.6/1000 person-years; 42% (n=74) of deaths occurred during the pre-ART period and 39.8% (n=70) occurred during the first six months of ART. Of those who died during the pre-ART period, 94.5% were eligible for ART. In multivariate regression, baseline CD4 count and ART status were independent predictors of mortality, whereas ART status, younger age and patient volumes per provider were predictors of loss to follow-up. Probability of being alive and retained in care at six months was 96.8% among those on ART, 38.5% among pre-ART but eligible patients, and 20.0% among ART-ineligible patients.

Conclusions

Effectively supported private sector GPs successfully administered and monitored ART in Myanmar, suggesting that community-supported private sector partnerships can contribute to expansion of HIV treatment and care capacity. To further improve patient outcomes, early testing and initiation of ART, combined with close clinical monitoring and support during the initial periods of enrolling in treatment and care, are required.

Impact of an Adherence Program on the Health and Outlook of HIV-Infected Patients Failing Antiretroviral Therapy

BACKGROUND

We prospectively studied the impact of an adherence counselor on the outcome of patients failing antiretroviral therapy because of nonadherence.

METHODS

Forty-six patients, identified as chronically nonadherent were enrolled. Individual attention was provided using the information, motivation and behavioral methodology. HIV RNA (viral load, in copies/mL), CD4 count (in cells/mm(3)), and body weight before and after the adherence counselor were measured. Qualitative outcome and patient satisfaction were assessed by deidentified third-party interviews.

RESULTS

Over half completed at least 1 year; only 8 patients were lost to follow-up. Mean CD4 counts increased significantly (P < .05) for completers at 6 and 12 months. Viral loads decreased between baseline and 6 months. Most clients reported subjective benefit from working with the adherence counselor.

CONCLUSION

Although few clients showed complete virologic suppression, the value of an adherence counselor was validated. Longer term adherence programs should be evaluated.

Determination of optimized multidisciplinary care team for maximal antiretroviral therapy adherence

OBJECTIVE

We seek to determine the optimized multidisciplinary care team (MDCT) composition for antiretroviral therapy (ART) adherence.

METHODS

We analyzed all new regimen starts (n = 10,801; 7071 ART naive, 3730 ART experienced) among HIV-positive patients in Kaiser Permanente California from 1996 to 2006. We measured 12-month adherence to ART (pharmacy refill methodology) and medical center-specific patient exposure to HIV/infectious disease specialist (reference group), non-HIV primary care provider, clinical pharmacist, nurse case manager, non-nurse care coordinator, dietician, social worker/benefits coordinator, health educator, and mental health worker. We used recursive partitioning to ascertain potential MDCT compositions associated with maximal mean ART adherence. We then employed mixed linear regression with clustering by provider and medical center (adjusting for ART experience, age, gender, race/ethnicity, HIV risk, hepatitis C virus coinfection, ART regimen class, and calendar year) to test which potential MDCT combination identified had statistically significant association with ART adherence.

RESULTS

We found maximal increase in adherence with pharmacist plus coordinator plus primary care provider combination (8.1% ART adherence difference compared with reference; 95% confidence interval: 2.7% to 13.5%). Other MDCT teams with significantly (P < 0.05) improved adherence compared with specialist only were nurse plus social worker with primary care provider (7.5%; 5.4% to 9.7%), specialist plus mental health worker (6.5%; 2.6% to 10.4%), pharmacist plus social worker plus primary care provider (5.7%; 4.1% to 7.4%), and pharmacist plus primary care provider (3.3%; 0.8% to 5.8%). Among these MDCTs, there were no significant differences in mean adherence, odds of maximal viral control, or CD4+ changes at 12 months (except pharmacist plus primary care provider).

CONCLUSIONS

Various MDCTs were associated with improved adherence, including ones that did not include the HIV specialist but included primary care plus other health professionals. These findings have application to the HIV care team design.

[Multidisciplinary perspective on support for antiretroviral therapy adherence in Andalusia. Andhalusida study]

OBJECTIVE

To analyse physicians', pharmacists' and nurses' perspectives on the importance of different antiretroviral treatment adherence support activities and identify the main obstacles to meeting established recommendations which health professionals encounter.

METHOD

Cross-sectional observational and analytical study. Three questionnaires were designed based on 2008 GESIDA/SEFH/PNS recommendations for improving treatment adherence: "ideal measures" (IM), "real measures" (RM) and "adherence support problems" (ASP). Cronbach's Alpha index was determined to analyse questionnaire reliability and correlation coefficients between the MI and MR scales. We applied the Chi-square test or Monte Carlo method to analyse the correlation between health providers and items on the three questionnaires.

RESULTS

Participants consisted of 58 health professionals. The response rate was 76%. The Cronbach Alpha indices for the IM, RM and ASP questionnaires were 0.852, 0.933 and 0.818 respectively. The resulting intraclass correlation coefficient was 0.280. Significant differences were found for multiple comparisons of IM and RM questionnaires among physicians and pharmacists. The analysis of relationships between providers also found significant differences for one of the answers on the IM questionnaire, three on the RM and five on the ASP.

CONCLUSIONS

We observed that several health professionals have different perspectives on measures of support for treatment adherence, with differences arising mainly due to lack of time and training.

HIV quality of care assessment at an academic hospital: outcomes and lessons learned

Rapid changes in HIV treatment guidelines and antiretroviral therapy drug safety data add to the increasing complexity of caring for HIV-infected patients and amplify the need for continuous quality monitoring. The authors created an electronic HIV database of 642 patients who received care in the infectious disease (ID) and general medicine clinics in their academic center to monitor HIV clinical performance indicators. The main outcome measures of the study include process measures, including a description of how the database was constructed, and clinical outcomes, including HIV-specific quality improvement (QI) measures and primary care (PC) measures. Performance on HIV-specific QI measures was very high, but drug toxicity monitoring and PC-specific QI performance were deficient, particularly among ID specialists. Establishment of HIV QI data benchmarks as well as standards for how data will be measured and collected are needed and are the logical counterpart to treatment guidelines.

Essential components of effective HIV care: a policy paper of the HIV Medicine Association of the Infectious Diseases Society of America and the Ryan White Medical Providers Coalition

Human immunodeficiency virus (HIV) antiretroviral agents and effective HIV care management transformed HIV disease from a death sentence to a chronic condition for many in the United States. A comprehensive HIV care model was developed to meet the complex needs of HIV patients, with support from the Ryan White program, the Veterans Administration, and others. This paper identifies the essential components of an effective HIV care model. As access to health care expands under the National HIV/AIDS Strategy and the Patient Protection and Affordable Care Act, it will be critical to build upon the HIV care model to realize positive health outcomes for people with HIV infection.

Development and evaluation of a medication counseling workshop for physicians: can we improve on 'take two pills and call me in the morning'?

BACKGROUND

Physicians often do not provide adequate medication counseling.

PURPOSE

To develop and evaluate an educational program to improve physicians' assessment of adherence and their medication counseling skills, with attention to health literacy.

METHODS

We compared internal medicine residents' confidence and counseling behaviors, measured by self-report at baseline and one month after participation in a two-hour interactive workshop.

RESULTS

Fifty-four residents participated; 35 (65%) completed the follow-up survey. One month after training, residents reported improved confidence in assessing and counseling patients (p<0.001), including those with low health literacy (p<0.001). Residents also reported more frequent use of desirable behaviors, such as assessing patients' medication understanding and adherence barriers (p<0.05 for each), addressing costs when prescribing (p<0.01), suggesting adherence aids (p<0.01), and confirming patient understanding with teach-back (p<0.05).

CONCLUSION

A medication counseling workshop significantly improved residents' self-reported confidence and behaviors regarding medication counseling one month later.

HIV/AIDS Counseling Skills and Strategies: Can Testing and Counseling Curb the Epidemic?

OBJECTIVES

The human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) epidemic is in its third decade and has reached to alarming proportions worldwide. According to the Centers for Disease Control and Prevention, more than one million people are living with HIV with an estimated 56,300 infections happening each year in the United States. Diagnosis of HIV/AIDS via early testing along with pretest and post-test counseling is important for psychosocial stabilization and destigmatization. Risk reduction counseling as a preventive counseling method is equally important in high-risk individuals such as adolescents, substance abusers and in gay and bisexual population. The purpose of this review is to address a number of counseling strategies used for education and counseling of individuals at risk of getting HIV/AIDS and also among those who are HIV-infected.

METHODS

In order to collect materials for this review, a detailed search of CINAHL, MEDLINE, ERIC, Academic Search Premier, Scopus, Web of Science and Social Sciences Citation Index databases was carried out for the time period 1995-2010.

RESULTS

Some of the various dimensions of counseling are negative approach counseling, assessing readiness to change, and motivational enhancement therapy.

CONCLUSIONS

Multiple approaches are used by counselors in providing education and prevention counseling to 'at risk' individuals and also individuals who have been infected with the virus. No one method is superior to another and some gamut of techniques are practiced by HIV/AIDS counselors.

Effectiveness of a training program to increase the capacity of health care providers to provide HIV/AIDS care and treatment in Swaziland

Implementation of HIV care and treatment programs in sub-Saharan Africa is a complex undertaking that requires training of health care providers (HCPs). Many sub-Saharan African countries have introduced training programs to build human resources for health. Evaluation of the ongoing trainings is warranted so that programs can be improved. The purpose of this study was to evaluate Baylor International Pediatric AIDS Initiative's (BIPAI) HCP training program in Swaziland. The specific aims were: (1) to assess coverage and delivery of the training program; and (2) to determine the impact of the training program on HCPs' knowledge about HIV and pediatric practices, attitudes toward HIV/AIDS patients, and self-efficacy to provide antiretroviral therapy (ART). The evaluation was a multimethod design with two types of data collection and analysis: (1) one-group pretest-posttest survey with 101 HCPs; and (2) semi-structured in-depth interviews with seven trainers from Baylor College of Medicine and 16 local HCPs in Swaziland. Quantitative data were analyzed using Stata Statistical Software version 8.2 for descriptive and multivariate analysis while factor analysis was done using Statistical Program for Social Sciences version 14. The transcribed interviews were analyzed using a didactic approach. Process evaluation showed that the training had good coverage, was delivered as intended, and improved as the work progressed. The training program led to a significant increase (p=0.0000) in HCPs' knowledge about HIV/AIDS, ART, and relevant clinical pediatrics practices between pretest (mean 68.7% SD 13.7) and post training (mean 84.0% SD 12.0). The training program also increased trainees' self-efficacy to provide ART and their attitudes toward AIDS patients (p=0.0000 and 0.02, respectively). In conclusion, BIPAI training program in Swaziland had good coverage of all health care facilities and HCPs in Swaziland. The training was effective in imparting knowledge and skills to HCPs and in their attitudes toward HIV/AIDS patients.

Provider-focused intervention increases adherence-related dialogue but does not improve antiretroviral therapy adherence in persons with HIV

BACKGROUND

Physicians' limited knowledge of patients' antiretroviral adherence may reduce their ability to perform effective adherence counseling.

METHODS

We conducted a randomized, cross-over study of an intervention to improve physicians' knowledge of patients' antiretroviral adherence. The intervention was a report given to the physician before a routine office visit that included data on Medication Event Monitoring System and self-reported data on antiretroviral adherence, patients' beliefs about antiretroviral therapy, reasons for missed doses, alcohol and drug use, and depression. We audio recorded 1 intervention and 1 control visit for each patient to analyze differences in adherence-related dialogue.

RESULTS

One hundred fifty-six patients were randomized, and 106 completed all 5 study visits. Paired audio recorded visits were available for 58 patients. Using a linear regression model that adjusted for site and baseline Medication Event Monitoring System adherence, adherence after intervention visits did not differ significantly from control visits (2.0% higher, P = 0.31, 95% confidence interval: -1.95% to 5.9%). There was a trend toward more total adherence-related utterances (median of 76 vs. 49.5, P = 0.07) and a significant increase in utterances about the current regimen (median of 51.5 vs. 32.5, P = 0.0002) in intervention compared with control visits. However, less than 10% of adherence-related utterances were classified as "problem solving" in content, and one third of physicians' problem-solving utterances were directive in nature.

CONCLUSIONS

Receipt of a detailed report before clinic visits containing data about adherence and other factors did not improve patients' antiretroviral adherence. Analyses of patient-provider dialogue suggests that providers who care for persons with HIV may benefit from training in adherence counseling techniques.

The adherence support gap: the 'ideal' versus 'reality' of antiretroviral adherence support provided by HIV health providers in clinical practice

BACKGROUND

Guidelines suggest that clinicians should provide their patients with antiretroviral adherence support, but there is uncertainty about the types of adherence support clinicians think are important, the methods they use to provide adherence support, and the barriers they face in providing such support in clinical practice.

OBJECTIVE

To study clinician perspectives on the importance of different antiretroviral adherence support activities and compare these with clinicians' self-reported actual adherence support practices.

METHODS

From March to August 2005, surveys were mailed to physicians, pharmacists, and nurses who provide care to HIV patients in Ontario, Canada. The 84-item survey asked providers to rate how necessary it was to provide 30 types of adherence support activities and how frequently they actually provided each of the types of adherence support. From this, we assessed healthcare provider perceptions of best or ideal practices in supporting medication adherence and actual or usual care in adherence support provision. We also examined whether an adherence support gap existed between the provision of best practice adherence support and actual adherence support in clinical practice.

RESULTS

One hundred sixty-nine of 300 mailed surveys were returned, for a response rate of 56%. Respondents were highly specialized in HIV care and nearly all practiced in urban settings. Respondents indicated that most of the surveyed adherence support activities should be provided to all patients. However, most clinicians did not actually provide these adherence supports to their patients to the extent that they desired. We calculated an adherence support gap that ranged from 31% to 75% across the different types of adherence support activities.

CONCLUSIONS

We observed important adherence support gaps between ideal best practices in the provision of adherence support and actual provision of adherence support in clinical practice.

The challenges of assessing fidelity to physician-driven HIV prevention interventions: lessons learned implementing Partnership for Health in a Los Angeles HIV clinic

Documenting fidelity to HIV prevention interventions is critical to ensure consistency in intervention implementation and necessary for measuring intervention exposure and, ultimately, outcomes. Significant variation from prescribed protocols or inconsistent implementation can jeopardize the integrity of evaluation research and render outcomes uninterpretable. There is increasing support for HIV prevention models targeting seropositive individuals designed to be delivered by physicians during clinic visits. Assessing fidelity to physician-delivered interventions that occur during clinical exams present unique challenges. This paper presents findings from various data sources designed to track intervention fidelity and exposure to the Partnership for Health intervention, a physician-delivered HIV prevention intervention implemented in an urban community HIV clinic. We present findings from chart abstraction data, patient surveys and exit interviews, and provider qualitative interviews. Lessons learned and recommendations for maximizing the accuracy and validity of fidelity assessment in future evaluations of HIV prevention interventions in primary care settings are considered.

Patient satisfaction with antiretroviral services at primary health-care facilities in the Free State, South Africa--a two-year study using four waves of cross-sectional data

Background

The study's first objective was to determine the levels of patient satisfaction with services at antiretroviral treatment (ART) assessment sites. Differences in patient satisfaction with several aspects of service over time and among health districts were measured. The second objective was to examine the association between human resource shortages and levels of patient satisfaction with services.

Methods

Four cross-sectional waves of data were collected from a random sample of 975 patients enrolled in the Free State's public-sector ART programme. One-way analysis of variance (ANOVA) with the Bonferroni adjustment for multiple comparisons was used to assess the differences in patient satisfaction among the Province's five districts and among the four waves of data. Correlation coefficient analysis using Pearson's r was used to assess the association between ART nurse vacancy rates and patient satisfaction with the services provided by nurses over time.

Results

With respect to both general services and the services provided by nurses, our results indicate high overall satisfaction among Free State patients receiving public-sector ART. However, our data present a less positive picture of patient satisfaction with waiting times. Patients in Fezile Dabi District were generally slightly dissatisfied with the waiting times at their assessment sites. In fact, waiting times at assessment sites were the most important predictor of discontent among ART patients. Significant geographical (P < 0.001) and temporal differences (P < 0.005) were observed in these three aspects of patient satisfaction. Patients were most satisfied in Thabo Mofutsanyana District and least satisfied in Motheo District. Patients in Fezile Dabi District were generally slightly dissatisfied with the waiting times at their assessment sites. Finally, our analysis revealed a strong negative association (r = -0.438, P < 0.001) between nurse vacancy rates and mean satisfaction levels with services performed by nurses at baseline. Patients attending facilities with high professional nurse vacancy rates reported significantly less satisfaction with nurses' services than did those attending facilities with fewer vacant nursing posts.

Conclusion

Collectively, our findings show high levels of patient satisfaction with ART-related services, but also confirm claims by other studies, which have identified human resource shortages as the most important obstacle to a successful South African AIDS strategy.

Translating concern into action: HIV care providers' views on counseling patients about HIV prevention in the clinical setting

Recent Centers for Disease Control (CDC) guidelines recommend that HIV care practitioners provide HIV prevention counseling to patients at routine medical visits. However, research shows that HIV care practitioners provide such counseling infrequently, presenting a challenge for clinics implementing these guidelines. Our qualitative study of 19 HIV care providers at an infectious diseases clinic in the southeastern US explored providers' beliefs about their patients' HIV transmission behaviors, expected outcomes of conducting HIV prevention counseling, and perceived barriers and facilitators to counseling. Providers' concern about HIV transmission among their patients was high but did not "translate into action" in the form of counseling. They anticipated poor outcomes from counseling, including harm to patient-provider relationships, and failure of patients to change their behavior. They also listed barriers and facilitators to counseling, most importantly time, state reporting policies, and conversational triggers. Implications for implementation of CDC guidelines and clinic-based "Prevention with Positives" programs are discussed.

"It's my body'': does patient involvement in decision making reduce decisional conflict?

OBJECTIVE

This study explores how much people with HIV/AIDS wanted and how much they actually perceived being involved in the decision to take or not to take antiretroviral treatment (ART). The congruence between desired and perceived decisional involvement was also related to decisional conflict.

METHOD

Cross-sectional (N = 79), the Control Preferences Scale assessed patients' preferred versus perceived role in treatment decision making. The Decisional Conflict Scale measured patients' perceived difficulties in decision making.

RESULTS

Although a minority of patients (32%) perceived their role as shared decision making, the majority (59%) preferred shared decision making. Some did not desire shared decision making, with 28% preferring to decide on their own versus 13% wanting their physicians to decide for them. Overall, 58% did not feel they had achieved their desired role in decision making (half of whom perceived more control and the other half less control than preferred). Participants declining ART felt more pressure to decide alone compared with those taking ART (P < 0.01). Decisional conflict was expressed by 53% and was highest when physicians unilaterally made decisions about ART for patients who preferred shared decision making (P < 0.001).

CONCLUSIONS

In this study, most physicians do not meet their patients' desired roles in decision making. One-third of people taking ART feel less involved than they desire. More critically, half of those declining ART feel pressured to decide alone, suggesting that physicians should remain involved in the decision to reject treatment, as this requires careful monitoring and periodical revisiting. Because lack of shared decision making is related to decisional conflict, physicians may reduce decisional conflict by meeting patients' desires for shared decision making.

Effect of clinical pharmacists on utilization of and clinical response to antiretroviral therapy

OBJECTIVE

To determine the association of clinical pharmacists with health outcomes and utilization measures among HIV-infected patients.

METHODS

Observational study of 1571 HIV-infected patients prescribed their initial highly active antiretroviral therapy (HAART) regimen in clinics with and without a clinical pharmacist. Outcomes analyzed were changes in plasma HIV RNA level, CD4 T-cell counts, and service utilization (hospital days, emergency department visits, and office visits) over 24 months based on exposure to a clinical pharmacist.

RESULTS

Patients exposed to a clinical pharmacist tended to be more likely to achieve an HIV RNA level <500 copies/mL at 12 months (adjusted odds ratio [OR] = 2.01, 95% confidence interval [CI]: 0.92 to 4.37). At 24 months, however, results depended on the provider panel size; the ORs for panel sizes < or =50 and >50 HIV-infected patients were 1.67 (95% CI: 0.60 to 4.62) and 0.97 (95% CI: 0.39 to 2.41), respectively. CD4 T-cell counts were modestly but nonsignificantly higher for the patients exposed to a clinical pharmacist. Utilization also depended on the provider panel size; pharmacist exposure was associated with 64% (95% CI: 30% to 108%) and 9% (95% CI: -11% to 33%) increases in total hospital days for panel sizes < or =50 and >50 HIV-infected patients, respectively. Pharmacist exposure was also associated with a 19% (95% CI: -13% to -24%) decrease in office visits for panel sizes < or =50 HIV-infected patients, with minimal effect for larger panel sizes.

CONCLUSION

Clinical pharmacists seem to contribute to lower office visit rates in antiretroviral-naive patients initiating HAART.

Physicians' communication with patients about adherence to HIV medication in San Francisco and Copenhagen: a qualitative study using Grounded Theory

BACKGROUND

Poor adherence is the main barrier to the effectiveness of HIV medication. The objective of this study was to explore and conceptualize patterns and difficulties in physicians' work with patients' adherence to HIV medication. No previous studies on this subject have directly observed physicians' behavior.

METHODS

This is a qualitative, cross-sectional study. We used a Grounded Theory approach to let the main issues in physicians' work with patients' adherence emerge without preconceiving the focus of the study. We included physicians from HIV clinics in San Francisco, U.S.A. as well as from Copenhagen, Denmark. Physicians were observed during their clinical work and subsequently interviewed with a semi-structured interview guide. Notes on observations and transcribed interviews were analyzed with NVivo software.

RESULTS

We enrolled 16 physicians from San Francisco and 18 from Copenhagen. When we discovered that physicians and patients seldom discussed adherence issues in depth, we made adherence communication and its barriers the focus of the study. The main patterns in physicians' communication with patients about adherence were similar in both settings. An important barrier to in-depth adherence communication was that some physicians felt it was awkward to explore the possibility of non-adherence if there were no objective signs of treatment failure, because patients could feel "accused." To overcome this awkwardness, some physicians consciously tried to "de-shame" patients regarding non-adherence. However, a recurring theme was that physicians often suspected non-adherence even when patients did not admit to have missed any doses, and physicians had difficulties handling this low believability of patient statements. We here develop a simple four-step, three-factor model of physicians' adherence communication. The four steps are: deciding whether to ask about adherence or not, pre-questioning preparations, phrasing the question, and responding to the patient's answer. The three factors/determinants are: physicians' perceptions of adherence, awkwardness, and believability.

CONCLUSION

Communication difficulties were a main barrier in physicians' work with patients' adherence to HIV medication. The proposed model of physicians' communication with patients about adherence--and the identification of awkwardness and believability as key issues--may aid thinking on the subject for use in clinical practice and future research.

The importance of establishing regimen concordance in preventing medication errors in anticoagulant care

Miscommunication between patients and providers can have serious consequences, especially where medications are concerned. We examined whether regimen discordance between patient and provider, a possible result of miscommunication, contributes to unsafe medication management. We studied 220 patients taking warfarin in an anticoagulation clinic to characterize two medication assessment methods. We measured (1) adherence by asking patients to report any missed doses and (2) concordance between patients' and providers' reports of warfarin regimens. We categorized patients as having regimen adherence if they missed no doses, and concordance if there was patient-provider agreement in weekly dosage. We characterized anticoagulant outcomes as unsafe if international normalized ratio (INR) values were <2.0 (at risk for thrombosis) or >4.0 (at risk for hemorrhage), and explored relationships among adherence, concordance, and anticoagulant outcomes. One hundred fifty-five patients (71%) reported no missed doses during the prior 30 days. Poor adherence was associated with underanticoagulation (AOR 2.33, 1.56-3.45), but not overanticoagulation (AOR 1.36, 0.69-2.66). One hundred ten patients (50%) reported regimens discordant with clinicians' report. There was no relationship between patients' reports of adherence and concordance. Among adherent patients, discordance was associated with underanticoagulation (AOR 1.67, 1.00-2.78) and overanticoagulation (AOR 3.44, 1.32-9.09). Discordance regarding warfarin regimens is common and places patients at risk for adverse events. To promote safe and effective care, clinicians should separately determine adherence and regimen concordance during routine medication assessments. Systems need to be developed to ensure concordance in medication regimens.

To take or not to take: decision-making about antiretroviral treatment in people living with HIV/AIDS

Knowledge is limited regarding decision-making about antiretroviral treatment (ART) from the patient's perspective. This substudy of a longitudinal study of psychobiologic aspects of long-term survival, conducted in 2003, compares the rationales of HIV-positive individuals (n = 79) deciding to take or not to take ART. Inclusion criteria were HIV/AIDS symptoms, or CD4 nadir less than 350, or viral load greater than 55,000. Those not meeting any criteria for receiving ART (2/2003 U.S. DHHS treatment guidelines) were excluded. Diagnosis was on average 11 years ago; 36% were female, 42% African American, 28% Latino, 24% white, and 6% other. Qualitative content analysis of semistructured interviews identified 10 criteria for the decision to take or not to take ART: CD4/viral load counts (87%), quality of life (85%), knowledge/ beliefs about resistance (66%), mind-body beliefs (65%), adverse effects of ART (59%), easy-to-take regimen (58%), spirituality/worldview (58%), drug resistance (41%), experience of HIV/AIDS symptoms (39%), and preference for complementary/alternative medicine (17%). Participants choosing not to take ART (27%) preferred complementary/alternative medicine (r = 0.43, p = 0.001)1, perceived a better quality of life without ART (r = 0.32, p < 0.004), and weighted avoidance of adverse effects of ART more heavily (r = 0.24, p < 0.030) than participants taking ART (73%). Demographic characteristics related to taking ART were having a partner (r = 0.31, p < 0.008) and having health insurance (r = 0.26, p< 0.040). Decisions to take or not to take ART depend not only on patient medical characteristics, but also on individual beliefs about ART, complementary/alternative medicine, spirituality, and mind-body connection. HIV-positive individuals declining treatment place more weight on alternative medicine, avoiding adverse effects and perceiving a better quality of life through not taking ART.

Paradoxical effects of clinician emphasis on adherence to combination antiretroviral therapy for HIV/AIDS

Constructive relationships between clinicians and patients being treated for HIV/AIDS are critical to treatment success. Trust, caring, and expertise have all been cited as important components of such relationships. As-yet unexamined, however, is the impact of the urgency patients sense in their clinicians concerning proper adherence to antiretroviral medications. Qualitative interviews (total, 214) from a study of adherence to highly active antiretroviral therapy (HAART) for active illegal drug users (n = 52) provided data for the analysis. Among other topics, interviews examined patients' perspectives on relationships with their providers. Study participants experienced their physicians as insisting on perfect adherence. Fearing disapproval if they disclosed missing doses, interviewees chose instead to conceal adherence information. Apprehensions about failing at perfect adherence led some to cease taking antiretrovirals over the course of the study. Well-intentioned efforts by clinicians to emphasize the importance of adherence can paradoxically undermine the very behavior they are intended to promote. Adherence can be approached in ways that inspire honesty and openness and build trust in the treatment relationship, laying the groundwork for a collaborative approach to solving problems in taking antiretroviral medications as prescribed.

Positive provider interactions, adherence self-efficacy, and adherence to antiretroviral medications among HIV-infected adults: A mediation model

Adherence to antiretroviral (ARV) therapy for HIV infection is critical for maximum benefit from treatment and for the prevention of HIV-related complications. There is evidence that many factors determine medication adherence, including adherence self-efficacy (confidence in one's ability to adhere) and relations with health care providers. However, there are no studies that examine how these two factors relate to each other and their subsequent influence on HIV medication adherence. The goal of the current analysis was to explore a model of medication adherence in which the relationship between positive provider interactions and adherence is mediated by adherence self-efficacy. Computerized self-administered and interviewer-administered self reported measures of medication adherence, demographic and treatment variables, provider interactions, and adherence self-efficacy were administered to 2765 HIV-infected adults on ARV. Criteria for mediation were met, supporting a model in which adherence self-efficacy is the mechanism for the relationship between positive provider interactions and adherence. The finding was consistent when the sample was stratified by gender, race, injection drug use history, and whether the participant reported receipt of HIV specialty care. Positive provider interactions may foster greater adherence self-efficacy, which is associated with better adherence to medications. Results suggest implications for improving provider interactions in clinical care, and future directions for clarifying interrelationships among provider interactions, adherence self-efficacy, and medication adherence are supported.